Many questions arise with regard to the observance of mitzvot by a person suffering from dementia¹. For example, should he be prevented from desecrating Shabbat when he is unaware that it is Shabbat? How should one behave in the reverse case, when the patient thinks that a weekday is Shabbat and demands that everyone else act accordingly? Should one help him don tefillin and pray when it is not clear if he understands what he is doing? What about the assistance of a non-Jewish carer? Is it permitted to transfer him to a nursing home where kashrut and Shabbat are not observed? (This is a question we receive regularly from people living outside of Israel) Another consideration is the preservation of the patient’s dignity – is there any significance to the fact that he apparently does not feel that his dignity has been impaired?

1. In principle, an elderly man and an invalid are obligated in mitzvot like any other person.

2. If observing positive mitzvot is very burdensome for a person suffering from dementia and he might be harmed in the process, he is exempt². However, we should take into account that observing mitzvot must be considered part of maintaining his regular life routine and dignity.

3. If the dementia patient is only vaguely aware of what is going on around him, his obligation to fulfill mitzvot depends on his level of comprehension. He is obligated like anyone else to observe those mitzvot that he understands, whereas he is exempt from those mitzvot that he does not understand or of which he is unaware³.

4. A debilitated patient, who finds praying extremely onerous, is exempt from prayer, just as he is exempt from other positive mitzvot whose fulfillment is very difficult for him. It is not appropriate to pressure him to pray or fulfill other mitzvot. That said, if the patient wants to pray but is unable to cope with the full prayer service, he may recite a shortened version and skip parts of the service. On the Tzohar Ad 120 website there is an abridged prayer service for debilitated patients, which outlines the preferential order and stages of prayer⁴.

5. A patient who is suffering and whose mind is unsettled is exempt from donning tefillin. If he wishes to be stringent with himself, he is permitted to don tefillin⁵.

6. An invalid who is unable to keep his body clean is exempt from donning tefillin. If it is hard for him to keep his body clean and yet he wants to don tefillin, he may do so for a brief period⁶. If the patient is attached to a catheter, through which urine drips into a bag or container, he is permitted to perform all ritual observances, such as reciting Shema, praying, reciting Grace after Meals, learning Torah, and donning a tallit and tefillin with a blessing, provided that his outer garments are clean and no foul odor is emitted by the container that holds the urine. Ideally one should cover the catheter and urine receptacle⁷. If he cannot control his bodily functions, and feces are constantly coming out of his body, he should be cleaned thoroughly before praying, and recite only a brief prayer⁸.

7. If the patient is unable to don tefillin himself, and there is no man who can do it for him, a woman may help him don tefillin. If necessary, even a minor or a non-Jewish carer may help him do so, and the patient should recite the blessing, after the tying of the tefillin rather than before, as he otherwise would⁹.

8. If a female patient is unable to light Shabbat candles herself, another member of her family should do so. Although it is preferable for the one lighting the candles to recite the blessing, a woman who has dementia may recite the blessing, as this is part of her regular routine and it is beneficial to her. The same applies to any invalid, if the inability to recite the blessing might cause them distress¹⁰.

9. When there is no other family member in the house, a non-Jewish carer may help the woman light the candles, and the patient should recite the blessing immediately after the candles are lit¹¹.

10. The obligation to prevent a patient from violating a prohibition (such as eating on Yom Kippur, turning on a light on Shabbat, or a different form of Shabbat desecration) also depends on his level of awareness. If he is aware of the prohibitions but not the circumstances, and a reminder will help him, one may tell him not to commit the transgression. However, if he has no understanding of the meaning of the prohibition at all, there is no need to make things difficult for him¹². Nevertheless, if he is in a public place, and violating the prohibition might dishonor him, it is proper to prevent him from doing so.

11. Even a patient who has lost all cognitive functionality should not be given non-kosher food. If he asks to eat milk after meat, we may be lenient and give it to him one hour after eating meat, even if his usual custom is different. If it is impossible to explain to him that he must wait, one may even give him milk immediately after the meal¹³.

12. Admitting a dementia patient into an institution where halakha is not observed generates complex halakhic issues¹⁴.One should consult a rabbi in each particular case. In certain exceptional situations it is permitted to do so.

1. We dealt with this at length in the position paper, “The Fulfillment of Mitzvot by an Invalid” (https://bit.ly/3EkoD1m); see also our suggestion for an “Order of Prayer and Grace after Meals for a Debilitated Patient” (https://bit.ly/32o9eju). Here we present the basic principles and some of the details that are particularly relevant to a patient with dementia. See Rabbi Avraham Sofer Avraham, “The Elderly Patient: Problems of Nursing from a Halakhic Perspective,” Assia 6 (1989), pp. 133–40; Encyclopedia of Medicine and Halakha, vol. 3, “The Patient,” pp. 429–57; Rabbi Y. Zilberstein, “Respecting a Father Suffering from Dementia,” Rabbi Yehuda Shaviv (ed.), Devarim She’ein Lahem Shi’ur, Alon Shevut 2015, pp. 146–54; Rabbanit Michal Tikochinsky, “Ageing and the Treatment of Ageing in Halakha,” Teḥumin, 41 (2021), p. 266–79.
2. See Iggerot Moshe, Oraḥ Ḥayyim, I:172. Rabbi Feinstein rules that a patient was not required to leave the hospital in order to hear the shofar, since one is not required to spend more than a fifth of his possessions in order to fulfill positive mitzvot, and the preservation of one’s health is more important than all his money. In Kovetz Shi’urim II:46, 1, Rabbi Elchanan Wasserman writes that an invalid and those attending him are exempt from prayer, in accordance with the rule that “One who is engaged in a mitzva is exempt from the other mitzvot,” and a sick person is considered to be engaged in the mitzva of “restoring his body.” Rabbi Eliezer Waldenberg (Tzitz Eliezer, XIV:27, 1) maintains that a person is under no obligation to make himself ill or suffer in order to force himself to eat an olive-bulk of matza or bitter herbs, or drink four cups of wine on Seder Night, even if this does not pose a danger to his life. This is also the conclusion of Rabbi Yaakov Ariel in BeOhala Shel Torah, II:92: “If the posek determines that a patient will only be able to fulfill a positive mitzva with great difficulty and through much suffering, he is exempt from the observance of the mitzva.”
3. This is how Rabbi Zalman Nechemia Goldberg defines the status of a mentally compromised individual (“The Marriage of Mentally Retarded Individuals,” Teḥumin, 7 (1986), p. 239). It should be emphasized that a person suffering from dementia is not a fool or a simpleton, though the Hebrew equivalent of these terms seems to be the closest halakhic model for such a patient. Rabbanit Michal Tikochinsky (“Ageing and the Treatment of Ageing in Halakha,” see footnote 110, above) discusses the halakhic status of the elderly in great depth and proposes a model of obligation in the mitzvot that is directly related to his level of understanding and awareness, as well as the subjective awareness required for one to be obligated in each specific mitzva. The precise definition thus depends on changing variables, as the Rambam writes with regard to the suitability of a mentally compromised individual to submit testimony: “This matter is in accordance with how the judge sees it, as it cannot be formulated in writing” (Mishne Torah, Hilkhot Edut 9:10).
4. See footnote 110, above.
5. Rama, Oraḥ Ḥayyim, 38:1; Mishna Berura ibid., 5.
6. ^[1] With regard to someone suffering from an intestinal disease, see Shulḥan Arukh, Oraḥ Ḥayyim 38:1; Magen Avraham ibid., 1; Mishna Berura ibid., 1–4; Tzitz Eliezer, XX:45, question 3.
7. According to Rabbi Moshe Feinstein, one must cover the catheter (Iggerot Moshe, Oraḥ Ḥayyim, I:27). Rabbi Eliezer Waldenberg (Tzitz Eliezer, VIII:1) maintains this is an act of piety, and Rabbi S. Z. Auerbach contends that there is no obligation to cover it (as cited by Rabbi A.S. Avraham, “The Elderly Patient: Problems of Nursing Care from a Halakhic Perspective,” Assia 6 (1989), pp. 135, as well as in Nishmat Avraham, Oraḥ Ḥayyim, 76:9). See also Or LeTzion, II:6, 15; Yalkut Yosef, 76:25.
8. Shulḥan Arukh, Oraḥ Ḥayyim 76:4; Mishna Berura ibid., 16. See also footnote 115, above. Compare this to the position of the poskim who permit a patient whose abdominal wall had been opened to allow the stool to exit (intestinal feces), to recite Shema, pray, study Torah, and don tefillin – after the tube has been cleaned, the exit area covered, and the odor removed (Tzitz Eliezer, IX:6; Rabbi S. Z. Auerbach, as cited in Nishmat Avraham, Oraḥ Ḥayyim, 76:9; Minḥat Yitzḥak, VI:11–12; X:8; Shevet HaLevi, III:17).
9. With regard to donning tefillin with the aid of a woman, see the Responsa of the Maharam Schick, Oraḥ Ḥayyim 15; Yehuda Ya’ale (Aszód), Oraḥ Ḥayyim 19; Kaf HaḤayyim, Oraḥ Ḥayyim 27:8; Yabia Omer, IX, Oraḥ Ḥayyim 7:2; see also his comments in Taharat HaBayit (Jerusalem, 1990) II:12, 45 (in Mishmeret HaTahara, p. 215, he writes that even a woman who is a nidda can help her husband don tefillin); Shevet HaLevi, I:8; Tzitz Eliezer, XIII:7; Nishmat Avraham, Oraḥ Ḥayyim, 27:2. For further discussion about donning tefillin with the assistance of a gentile, see Rabbi Shimon Ben Shlomo, “Donning Tefillin by means of a Woman and Idol-worshipper,” Yeshurun 19 (September 2007), pp. 551–59. He concludes, citing Rabbi Y. S. Elyashiv, that a woman and a gentile (though they are obviously not on equal footing) may help a patient don tefillin if nobody else is available, and the patient should recite the blessing when he is wearing the tefillin, rather than before tying them. See also the comments of the rabbis and rabbaniyot of Beit Hillel, “A Halakhic Perspective on the Employment and Rights of Foreign Carers,” Beit Hillel 18 (January 2020), p. 8 (https://bit.ly/3qYJ25E).
10. The Mishna Berura, 263:21, writes in the name of Derekh Ḥayyim that if a Jew was appointed to light the candles, he should recite the blessing rather than the one who sent him. However, in a situation where this might cause distress, one may rely on those poskim who maintain that the one who appointed the messenger should recite the blessing. See Piskei Teshuvot ibid., 21, who bases his ruling on the statement of the Magen Avraham cited in the following footnote, among other sources. In the case of a woman suffering from dementia, it is important for her to maintain her regular routine, and therefore we can be lenient and allow her recite the blessing.
11. According to the Mishna Berura (see previous footnote) one may not light Shabbat candles through the agency of a non-Jewish carer, but the Magen Avraham (263:11) and the Shulḥan Arukh HaRav (ibid., 11) maintain that one may rely on the lenient position after the fact. According to the opinion of those poskim who permit this after the fact, one may also be lenient in a situation of need, such as a patient who will suffer great distress if they do not light the candles. See Piskei Teshuvot ibid., 19, and the position paper of Beit Hillel (footnote 118, above).
12. See Rabbanit Michal Tikochinsky, “Ageing and the Treatment of Ageing in Halakha,” footnote 110, pp. 274–75.
13. There are different customs regarding the amount of time that one must wait between eating meat and milk (Shulḥan Arukh, Yoreh De’a 89:1). For the patient’s sake one may follow the lenient opinion, which means it is sufficient to wait one hour. See Yabia Omer, I, Yoreh De’a 4; III, Yoreh De’a 3; Yalkut Yosef, Issur VeHeiter, 89:22–3. When the patient is cognitively impaired, one may be lenient and follow the basic law according to the most lenient opinion, which means giving him milk immediately after the conclusion of a meat meal.
14. See the Responsa of the Ḥatam Sofer, I:83; Iggerot Moshe, Oraḥ Ḥayyim, II:88, who discuss whether it is permitted to place a mentally impaired son or daughter in a non-kosher institution. See also Rabbanit Michal Tikochinsky, “Ageing and the Treatment of Ageing in Halakha,” footnote 110, p. 277; Rabbi Ariel Fixler, “‘Also, That the Soul Should Be Without Knowledge Is Not Good’ – Life Threatening Situations and Settling the Mind,” Tzohar 40 (2016) pp. 310–13.